How effectively does CBT-I address the traumatic and functional causes of insomnia and sleep disturbance in Veterans?


Cognitive-behavioural therapy for insomnia (CBT-I) continues to be recommended as the first-line treatment for an increasing number of Veterans seeking help for insomnia. Unfortunately, these recommendations are made on the basis of evidence from the general public, who do not experience the same predisposing, activating, and maintaining causes of insomnia as Veterans. This review considers whether CBT-I really addresses the causes of insomnia among Veterans, which can be labelled as functional (e.g., caffeine use) and traumatic (e.g., nightmares). Nine randomized controlled trials of CBT-I delivered to Veterans having trouble falling or staying asleep were reviewed. Evidence was not consistent enough to support the continued recommendation of CBT-I as a first-line treatment for insomnia among Veterans. On a wider level, the authors question whether psychological causes of a mental health problem are always, or should be, fully considered in the process of creating clinical guidelines for treatment.


Introduction: An interaction between functional and traumatic predisposing, precipitating, and perpetuating factors is suggested to explain the comparatively high prevalence of insomnia in the Veteran population. Cognitive-behavioural therapy for insomnia (CBT-I) has been recommended as a first-line treatment for insomnia in the Veteran community; however, little is known about the effectiveness of CBT-I for Veterans. This article reviews the findings and quality of nine randomized controlled trials (RCTs) of the effectiveness of CBT-I in the Veteran population with two objectives: 1) to assess whether the evidence exhibits the effectiveness of individual components of CBT-I and 2) to evaluate whether CBT-I is effective in addressing functional and traumatic causes of insomnia in this population. Methods: A search for suitable articles was conducted using a number of key terms, including Veterans, CBT-I, and insomnia, and then by applying inclusion and exclusion criteria. The findings and quality of nine RCTs were reviewed by two raters using the Critical Research Evaluation Schedule for Trainees, and inter-rater reliability was obtained. Results: The effectiveness of CBT-I across all measures of insomnia was inconsistent. Studies generally relied on unvalidated outcome measures and lacked adequate sample sizes and control of extraneous variables. Discussion: The findings presented did not support a stepped model of CBT-I for the treatment of insomnia among Veterans, which suggests the importance of reviewing current guidance for the treatment of Veterans with insomnia.

Full Reference

How effectively does CBT-I address the traumatic and functional causes of insomnia and sleep disturbance in Veterans?, 2022. Rigley, Jack, Neilson, Clare, Murphy, Dominic, and Watson, Fiona. Journal of Military, Veteran and Family Health 0 0:0